United Integrity Home Health Inc.

“Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice’s ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This Standard is not met as evidenced by: Based on interview and record review, the agency failed to ensure the emergency preparedness plan included an updated facility-based and community-based risk assessment utilizing an all-hazards approach, creating the potential risk of not providing the necessary care and services to the patients during the emergency events. Findings: Review of the agency’s 2024 emergency preparedness program documents was conducted on 1/28/25. * However, there was no documented evidence of the HHA’s updated facility-based and community-based risk assessment using an all-hazards approach. On 1/29/25 at 1000 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. She was informed and acknowledged the findings.”

“EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: Based on interview and record review, the agency failed to ensure the emergency preparedness plan analyze the response to the HHA’s emergency drills. This failure created the risk of not identifying the gaps in the HHA’s emergency program in responding to various types of emergencies. Findings: Review of the agency’s 2024 emergency preparedness program documents was conducted on 1/28/25. The Staff Meetings for Tsunami Ready Preparedness dated 3/15/23, and Earthquake Drill dated 10/19/23, showed the list of staff who attended the meetings. On 1/29/25 at 1000 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. She stated on 3/15/23 and 10/19/23, an individual facility based functional exercise and an emergency drill were conducted, respectively * However, there was no documented evidence the HHA had analyzed its response to the emergency drills on 3/15/23 and 10/29/23. On 1/29/25 at 1000 hours, the Administrator/DPCS was informed and acknowledged the findings.”

“12 hours inservice every 12 months CFR(s): 484.80(d) Standard: In-service training. A home health aide must receive at least l2 hours of in-service training during each 12-month period. In-service training may occur while an aide is furnishing care to a patient. This Standard is not met as evidenced by: Based on interview and clinical record review, the agency’s Administrator failed to be responsible for the day-to-day operations as the agency’s P&P related to the CHHA 12 hours in service training was completed for CHHA 3. This failure had the potential for not providing quality of care and services to the patients receiving services from the HHA. The agency’s P&P titled In-Service Training undated, showed the agency provides continuous in-service training program for all employees. The purpose was to provide employee competence, improve patient care and to improve employee efficiency. The procedures includes the documentation of attendance in in-service training session, and or completion of in-service training exercises is retained in the in-service training files with cross filing in the personnel record of the individual staff participating. All CHHA’s must have 12 hours of in-service per year. Review of the agency’s binder for 2024 In-service was initiated on 1/28/25. The binder showed the in-services and the post test trainings provided to the CHHA’s monthly. The binder also included the staff attendance form. The attendance form showed the agency had 4 CHHAs. Review of the CHHA 3’s personnel file showed the hiring date was 9/22/17. Review of the agency’s In-service training Binder showed CHHA 3’s in-services trainings. CHHA 3 attended an hour of in-service trainings for the months of January, February, March, April, May, June, July, August, September, and November 2024. However, review of the In-service training Binder failed to show documented evidenced of CHHA 3 attended the trainings for the month of October and December 2024 to complete the 12 hours in-service as per the agency’s P&P. On 1/19/25 at 0900 hours, an interview and concurrent document review was conducted with the LVN Case Manager. The LVN Case Manager was informed and acknowledged the findings.”

“Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This Standard is not met as evidenced by: Based on interview and record review, the agency failed to ensure the written patient care instructions for the CHHA was developed by the RN who was responsible for the supervision of the CHHA for three of eight sampled patients (Patients 1, 5, and 8). This failure had the potential for not addressing the care needs for these patients. Findings: 1. Review of Patient 1’s clinical record was initiated on 1/23/25. The clinical record showed the SOC was 6/12/24. The patient was certified for home health services during the certification period from 12/9/24 to 2/6/25. The Aide Care Plan for the certification period dated 12/9/24 to 2/6/25, showed HA visits 2W9. The care plan included CHHA to notify when the patient had no BM in three days. However, the care plan showed no documented evidence for the CHHA to obtain/record information of the patient’s bowel movement. On 1/29/25 at 0900 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS, Biller, and RN 2. They were informed and acknowledged the finding. 2. Review of Patient 8’s clinical record was initiated on 1/27/25. The clinical record showed the SOC was 9/1/24. The patient was certified for home health services during the certification periods from 10/31/24 to 12/29/24 and 12/30/24 to 2/27/25. The Aide Care Plan for the certification period dated 12/30/24 to 2/27/25, showed HA visits 2W9. The care plan included CHHA to notify when the patient had no BM in three days. However, the care plan showed no documented evidence for the CHHA to obtain/record information of the patient’s bowel movement. On 1/29/25 at 0934 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS, Biller, and RN 2. They were informed and acknowledged the finding. 3. Review of Patient 5’s closed clinical record was initiated on 1/24/25. The clinical record showed the SOC was 12/25/24. The patient was certified for home health services during the certification periods from 12/15/24 to 2/12/25. Review of the Aide Care Plan dated 12/15/24 cited aide visit 2W9 for the assessment of functional limitations, vital sign notification to include no bowel movement in 3 days, vital signs, activity for ambulation and transfer and personal care every visit. The care plan also includes the section for elimination. However, the care plan failed to show documented evidenced of the frequency to record bowel movement as the section was left blank. On 1/29/25 at 0935 hours, an interview and concurrent clinical record review was conducted with the Administrative Assistant/LVN. The Administrative Assistant/LVN was informed and acknowledged the findings. Findings: 1. Review of Patient 1’s clinical record was initiated on 1/23/25. The clinical record showed the SOC was 6/12/24. The patient was certified for home health services during the certification period from 12/9/24 to 2/6/25. The Aide Care Plan for the certification period dated 12/9/24 to 2/6/25, showed CHHA visits 2W9. The care plan included CHHA to notify when the patient had no BM in three days. However, the care plan showed no documented evidence for the CHHA to obtain/record information of the patient’s bowel movement. On 1/29/25 at 0900 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS, Biller, and RN 2. They were informed and acknowledged the finding. 2. Review of Patient 8’s clinical record was initiated on 1/27/25. The clinical record showed the SOC was 9/1/24. The patient was certified for home health services during the certification periods from 10/31/24 to 12/29/24 and 12/30/24 to 2/27/25. The Aide Care Plan for the certification period dated 12/30/24 to 2/27/25, showed CHHA visits 2W9. The care plan included CHHA to notify when the patient had no BM in three days. However, the care plan showed no documented evidence for the CHHA to obtain/record information of the patient’s bowel movement. On 1/29/25 at 0934 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS, Biller, and RN 2. They were informed and acknowledged the finding. 3. Review of Patient 5’s closed clinical record was initiated on 1/24/25. The clinical record showed the SOC was 12/25/24. The patient was certified for home health services during the certification periods from 12/15/24 to 2/12/25. Review of the Aide Care Plan dated 12/15/24 cited CHHA visit 2W9 for the assessment of functional limitations, vital sign notification to include no bowel movement in 3 days, vital signs, activity for ambulation and transfer and personal care every visit. The care plan also included the section for elimination. However, the care plan failed to show documented evidenced of the frequency to record bowel movement as the section was left blank. On 1/29/25 at 0935 hours, an interview and concurrent clinical record review was conducted with the Administrative Assistant/LVN. The Administrative Assistant/LVN was informed and acknowledged the findings.”

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on clinical record review and interview, the agency failed to ensure the initial assessment visits were conducted within 48 hours after referral for one of eight sampled patients (Patient 6). This failure had the potential for not providing the necessary care and services timely to this patient. Review of Patient 6’s closed clinical record was initiated on 1/27/25. The clinical record showed the referral date was 2/24/23, and the patient’s OASIS E-Start Of Care was 3/2/23. The patient was certified for home health services during the certification periods from 8/29/23 to 10/27/23 and 10/28/23 to 12/26/23. However, further review of the clinical record showed no documented evidence of the reason why the SOC was 3/2/23, instead of the 48 hours after the referral date of 2/24/23. On 1/29/25 at 1018 hours, an interview and concurrent clinical record review was conducted with the LVN Case Manager. The LVN Case Manager reviewed the clinical record and acknowledged the finding.”

“5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient’s immediate needs, but no later than 5 calendar days after the start of care. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the initial comprehensive assessments were completed in a timely manner, consistent with the patient’s immediate needs, but no later than 5 calendar days after the SOC date for four of eight sampled patients (Patients 2, 3, 6, and 8). This failure had the potential for not identifying and addressing the care needs timely for these patients. #. Review of Patient 2’s clinical record was initiated on 1/27/25. The clinical record showed the SOC was 12/3/24. The patient was certified for home health services during the certification period from 12/3/24 to 1/31/25. The OASIS-E Start of Care dated 12/3/24, showed the patient information for tetanus, TB, and hepatitis B immunization was not completed. In addition, the information about TB exposure was not completed. On 1/29/25 at 0915 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS, Biller, and RN 2. They were informed and acknowledged the finding. #. Review of Patient 8’s clinical record was initiated on 1/27/25. The clinical record showed the SOC was 9/1/24. The patient was certified for home health services during the certification periods from 10/31/24 to 12/29/24 and 12/30/24 to 2/27/25. The OASIS-E Start of Care dated 9/1/24, showed the patient information for patient’s weight, orientation to time, place, and situation were not completed. In addition, the patient’s TB, and hepatitis B immunization; and TB exposure were not completed. On 1/29/25 at 0934 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS, Biller, and RN 2. They were informed and acknowledged the finding. 1. Review of Patient 3’s clinical record was initiated on 1/23/25. The clinical record showed the SOC was 6/28/24. The patient was certified for home health services during the certification periods from 10/26/24 to 12/24/24 and 12/25/24 to 2/22/25. The OASIS - E Start of Care dated 6/28/24, showed the RN had performed the initial comprehensive assessment. The comprehensive assessment included the patient Most Recent Immunizations. The assessment showed the patient had immunization for pneumonia and flu. However, the RN did not complete the initial comprehensive assessment timely as the immunization on the sections for Tetanus, TB, TB Exposure and Hepatitis B immunization was left blank. On1/29/25 at 0947 hours, an interview and concurrent clinical record review was conducted with the LVN Case Manager. The LVN Case Manager was informed and acknowledge the findings. 2. Review of Patient 6’s closed clinical record was initiated on 1/27/25. The clinical record showed the SOC was 3/2/23. The patient was certified for home health services during the certification periods from 8/29/23 to 10/27/23 and 10/28/23 to 12/26/23. The OASIS- E Start of Care dated 3/2/23, showed the RN had performed the initial comprehensive assessment. The comprehensive assessment included the digestive body system. However, the section for digestive body system was left blank. On 1/29/25 at 1018 hours, an interview and concurrent clinical record review was conducted with the LVN Case Manager. The LVN Case Manager reviewed the clinical record and acknowledged the finding. Findings: 1. Review of Patient 3’s clinical record was initiated on 1/23/25. The clinical record showed the SOC was 6/28/24. The patient was certified for home health services during the certification periods from 10/26/24 to 12/24/24 and 12/25/24 to 2/22/25. The OASIS - E Start of Care dated 6/28/24, showed the RN had performed the initial comprehensive assessment. The comprehensive assessment included the patient’s most recent immunizations which were pneumonia and flu. However, the RN did not complete the assessment for other immunization as the immunization sections for Tetanus, TB, TB Exposure and Hepatitis B immunization were left blank. On1/29/25 at 0947 hours, an interview and concurrent clinical record review was conducted with the LVN Case Manager. The LVN Case Manager was informed and acknowledge the findings. 2. Review of Patient 6’s closed clinical record was initiated on 1/27/25. The clinical record showed the SOC was 3/2/23. The patient was certified for home health services during the certification periods from 8/29/23 to 10/27/23 and 10/28/23 to 12/26/23. The OASIS- E Start of Care dated 3/2/23, showed the RN had performed the initial comprehensive assessment. The comprehensive assessment included the digestive body system. However, the section for digestive body system was left blank. On 1/29/25 at 1018 hours, an interview and concurrent clinical record review was conducted with the LVN Case Manager. The LVN Case Manager reviewed the clinical record and acknowledged the findings. 3. Review of Patient 2’s clinical record was initiated on 1/27/25. The clinical record showed the SOC was 12/3/24. The patient was certified for home health services during the certification period from 12/3/24 to 1/31/25. The OASIS-E Start of Care dated 12/3/24, showed the patient’s tetanus, TB, and hepatitis B immunization were not completed. In addition, the information about TB exposure was not completed. On 1/29/25 at 0915 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS, Biller, and RN 2. They were informed and acknowledged the finding. 4. Review of Patient 8’s clinical record was initiated on 1/27/25. The clinical record showed the SOC was 9/1/24. The patient was certified for home health services during the certification periods from 10/31/24 to 12/29/24 and 12/30/24 to 2/27/25. The OASIS-E Start of Care dated 9/1/24, showed the patient’s weight, orientation to time, place, and situation were not completed. In addition, the patient’s TB, and hepatitis B immunization; and TB exposure were not completed. On 1/29/25 at 0934 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS, Biller, and RN 2. They were informed and acknowledged the findings.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on observation, interview, and record review, the agency failed to ensure the review of the medications included all of the patient’s current medications to identify any potential adverse effects and drug reactions for three of eight sampled patients (Patients 1, 2 and 3 ). This failure posed the risk for not identifying the potential adverse effects, significant drug interactions, duplicate drug therapy, and drug reactions for these patients. #. Review of Patient 1’s clinical record was initiated on 1/23/25. The clinical record showed the SOC was 6/12/24. The patient was certified for home health services during the certification period from 12/9/24 to 2/6/25. The Medication Profile for the certification period from 12/9/24 to 2/6/25, showed the patient’s medications included omeprazole (used to treat GERD) 40 mg one capsule daily. A joint home visit with CHHA 2 was conducted on 1/23/25 at 1016 hours, to Patient 1’s home. Review of the patient’s medications with the RCFE Administrator and CHHA 2. The RCFE Administrator stated omeprazole 40 mg one capsule daily was discontinued a month ago. On 1/29/25 at 0900 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS, Biller, and RN 2. They were informed and acknowledged the finding. #. Review of Patient 2’s clinical record was initiated on 1/27/25. The clinical record showed the SOC was 12/3/24. The patient was certified for home health services during the certification period from 12/3/24 to 1/31/25. The Medication Profile for the certification period from 12/3/24 to 1/31/25, showed the patient’s medications included Ativan (antianxiety) 0.5 mg one tablet at HS and levothyroxine sodium (hormone) 25 mcg one tablet daily. A joint home visit with the PTA was conducted on 1/23/25 at 1300 hours, to Patient 2’s home. Review of the patient’s medications with the patient was performed. The patient stated Ativan was taken when needed instead of routinely at HS and levothyroxine sodium was taken every other day instead of daily. On 1/29/25 at 0915 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS, Biller, and RN 2. The Administrator/DPCS stated the RN did not administer D5 1/2 NS. They were informed and acknowledged the finding. 1. Review of Patient 3’s clinical record was initiated on 1/23/25. The clinical record showed the SOC was 6/28/24. The patient was certified for home health services during the certification periods from 10/26/24 to 12/24/24 and 12/25/24 to 2/22/25. The Medication Profile for the certification period from 12/25/24 to 2/22/25, showed the patient’s medications included wound treatment for right foot - forefoot. Cleanse the wound with normal saline prior to applying a clean dressing. Do not scrub or use excessive force at time of dressing change. Apply mupirocin 2% ointment to wound daily then apply thin film of barrier ointment to protect skin surrounding the wound. Do not get ointment in the wound bed. Apply primary dressing to wound PRISMA then HFBR and secure with rolled gauze and tape change 3 times a week. Bactrim DS Oral (antibiotic) 800 -160 mg one tablet PO BID for 14 days, pantoprazole sodium oral (anti spasmodic) 40 mg one tablet PO before breakfast, metformin HCL oral (anti diabetic) 500 mg PO BID, Tresiba FlexTouch Subcutaneous (insulin)100 mg unit/ml inject 12 units subcutaneously every night at bedtime, Omeprazole Oral (antispasmodic) 40 mg one capsule PO QD, Ramipril Oral (antihypertensive) 5 mg one capsule PO QD, Rosuvastatin calcium oral (antihyperlipidemic) 20 mg PO QD, clopidogrel bisulfate oral (hematological) 75 mg PO QD, ferrous sulfate oral (hematopoietic) 325 mg (65 Fe) Mg one tablet PO BID, xarelto oral (anticoagulant) 2.5 mg PO BID, gabapentin oral (anticonvulsant) 300 mg three capsules BID and metoprolol succinate ER (beta blockers) 25 mg one table PO QD. A wound care orders dated 1/21/25 showed an order for wound care: Cleanse the wound with normal saline prior to applying a clean dressing. Do not scrub or use excessive force at time of dressing change. Apply thin film of barrier ointment to protect skin surrounding the wound. Do not get ointment in the wound bed. Apply topical antibiotic/antimicrobial in a thin film to wound bed then cover with clean dressing- mupirocin. Apply primary dressings to wound - HFBR and secure with rolled gauze and tape - change three times a week. A joint home visit with LVN 1 was conducted on 1/23/25 at 1000 hours, to Patient 3’s home. Review of the patient’s medications showed the instructions for Tresiba FlexTouch (insulin degludec) injection 100 units/ml was to administer 28 units under skin at bedtime instead of 12 units as written on the medication profile. On 1/23/25 at 1127 hours, an interview and concurrent clinical record review was conducted with the LVN 1. LVN 1 was informed and acknowledged the findings. On 1/29/25 at 0940 hours, the finding was shared with the LVN Case Manager. The LVN Case Manager acknowledged the finding.”

“Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure the comprehensive assessments were updated within the last five days of every 60 days for four of eight sampled patients (Patients 3, 4, 6, and 8 ). This failure had the potential for not addressing the care needs for these patients. #. Review of Patient 8’s clinical record was initiated on 1/27/25. The clinical record showed the SOC was 9/1/24. The patient was certified for home health services during the certification periods from 10/31/24 to 12/29/24 and 12/30/24 to 2/27/25. a. The OASIS-E Recertification dated 10/27/24, showed the patient information for patient’s TB, and hepatitis B immunization; and TB exposure were not completed. b. The OASIS E-Recertification dated 12/26/24, showed the patient information for patient’s height, weight, orientation to time, place, and situation were not completed. In addition, the patient’s TB, and hepatitis B immunization; and TB exposure were not completed. On 1/29/25 at 0934 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS, Biller, and RN 2. They were informed and acknowledged the finding. #. Review of Patient 4’s clinical record was initiated on 1/23/25. The clinical record showed the SOC was 8/2/24. The patient was certified for home health services during the certification periods from 10/2/24 to 11/29/24 and 11/30/24 to 1/28/25. The OASIS-E Recertification dated 9/27 and 11/29/24, showed no documented evidence the patient’s height and weight were completed. On 1/29/25 at 0905 hours, an interview and concurrent clinical record review was conducted with the Administrative Assistant/LVN. He was informed and acknowledged the finding. 1. Review of Patient 3’s clinical record was initiated on 1/23/25. The clinical record showed the SOC was 6/28/24. The patient was certified for home health services during the certification periods from 10/26/24 to 12/24/24 and 12/25/24 to 2/22/25. a. Review of the OASIS Recertification dated 12/20/24, showed the RN had performed a comprehensive assessment. The comprehensive assessment included a section for height and weight. However, the section for height and weight were left blank. In addition, on the section of Most Recent Immunization showed the patient had received immunization for Pneumonia and Flu. However, for the section on Tetanus, TB, TB Exposure and Hepatitis B immunization was left blank. On 1/29/25 at 0912 hours, an interview and concurrent clinical record review was conducted with the LVN Case Manager. The LVN Case Manager was informed and acknowledged the findings. b. Review of the OASIS Recertification dated 10/25/24, showed the RN had performed a comprehensive assessment. The assessment included a section for the Most Recent Immunization. The immunization showed the patient had received Pneumonia and Flu. However, for the section on Tetanus, TB, TB Exposure and Hepatitis B immunization was left blank. On 1/29/25 at 0947 hours, an interview and concurrent clinical record review was conducted with the LVN Case Manager. The LVN Case Manager was informed and acknowledged the findings. 2. Review of Patient 6’s closed clinical record was initiated on 1/27/25. The clinical record showed the SOC was 3/2/23. The patient was certified for home health services during the certification periods from 8/29/23 to 10/27/23 and 10/28/23 to 12/26/23. The OASIS Recertification dated 10/27/23, showed the RN had performed the comprehensive assessment. The comprehensive assessment included the section for height and weight. However, the section for height and weight were left blank. In addition, on the section of the body system assessment included the digestive system. However, the section for digestive body system was left blank. On 1/29/25 at 1018 hours, an interview and concurrent clinical record review was conducted with the LVN Case Manager. The LVN Case Manager was informed and acknowledged the finding.”

“Within 48 hours of the patient’s return CFR(s): 484.55(d)(2) Within 48 hours of the patient’s return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician or allowed practitioner - ordered resumption date; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the update comprehensive assessment was completed within 48 hours of the patient’s return to home from the acute care hospital for one of eight sampled patients (Patient 1). This failure created the risk of not providing the necessary care and services timely to meet the care needs for this patient. Findings: Review of Patient 1’s clinical record was initiated on 1/23/25. The clinical record showed the SOC was 6/12/24. The patient was certified for home health services during the certification period from 12/9/24 to 2/6/25. The OASIS-E1 Resumption of Care dated 1/5/25, showed the patient’s immunization for tetanus, TB, and hepatitis B immunization were not completed. In addition, the information about TB exposure and the assessment of the digestive system were not completed. On 1/29/25 at 0900 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS, Biller, and RN 2. They were informed and acknowledged the findings.”

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on interview and clinical record review, the agency failed to ensure the POCs included specific information related to medications and assessment of blood sugar for two of eight sampled patients (Patients 3 and 6). This failure had the potential for not addressing the care needs for these patients. 1. Review of Patient 3’s clinical record was initiated on 1/23/25. The clinical record showed the SOC was 6/28/24. The patient was certified for home health services during the certification periods from 10/26/24 to 12/24/24 and 12/25/24 to 2/22/25. The patient’s primary diagnoses was Type 2 Diabetes Mellitus with foot ulcer. a. The POC, for the certification period from 12/25/24 to 2/22/25, cited SN visits 1W1 (one visit a week for one week) and 2W8. The POC showed SN to assess blood sugar level via finger stick every visit prior to insulin administration and notify the physician if fasting blood sugar level greater than 300 mg/dl or less than 60 mg/dl and random blood sugar level greater than 400 mg/dl or less than 60 mg/dl. However, the POC failed to include specific instructions regarding the type of blood sugar testing needed to be performed during SN visits. On 1/29/25 at 0912 hours, an interview and concurrent clinical record review was conducted with the LVN Case Manager. The LVN Case Manager was asked if the SN needed to check both fasting and random blood sugar levels. The LVN Case Manager replied no, they did not have to check both, only the random blood sugar level. The LVN Case Manager was also asked if the instructions related to blood sugar check was specific in the POC. The LVN Case Manager replied no, it should be specific for random blood sugar check. The LVN Case Manager was further asked if the SN administered the patient’s insulin. The LVN Case Manager replied no, the patient’s insulin was to be given at night time. The LVN Case Manager was informed and acknowledged the findings. b. The POC, for the certification period from 10/26/24 to 12/24/24, cited SN visits 2W9. The POC cited SN to assess blood sugar level via finger stick every visit prior to insulin administration and notify the physician if fasting blood sugar greater than 300 mg/dl or less than 60 mg/dl and random blood sugar level greater than 400 mg/dl or less than 60 mg/dl. However, the POC failed to include specific instructions regarding the type of blood sugar testing needed to be performed during SN visits. In addition, review of the SN notes dated 11/29, 12/2 and 12/6/24, showed the blood sugar level was checked by the patient. However, the POC failed to include specific instruction for the patient to check the blood sugar levels during non SN visit days. On 1/29/25 at 0947 hours, an interview and concurrent clinical record review was conducted with the LVN Case Manager. The LVN Case Manager was asked if they needed to have a specific instructions in the POC for the patient to check the blood sugar levels on non SN days. The LVN Case Manager replied yes, it should have been written on the POC. The LVN Case Manager was informed and acknowledged the findings. 2. Review of Patient 6’s closed clinical record was initiated on 1/27/25. The clinical record showed the SOC was 3/2/23. The patient was certified for home health services during the certification periods from 8/29/23 to 10/27/23 and 10/28/23 to 12/26/23. The POCs, for the certification periods from rom 8/29/23 to 10/27/23 and 10/28/23 to 12/26/23, showed the patient’s medications included the following PRN medications. - acetaminophen (pain medication) 500 mg one tablet PO four times QD PRN for pain, - diclofenac sodium external (nonsteroidal anti-inflammatory medication) 1% 100 mg apply to affected area PRN for pain, and - Restasis ophthalmic (for dry eye) 0.05% 1 ml one drop on each eye PRN. However, the POCs did not include specific information as to when to administer these PRN medications. On 1/29/25 at 1018 hours, an interview and concurrent clinical record review was conducted with the LVN Case Manager. The LVN Case Manager was informed and acknowledged the findings.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure wound treatment was provided only with a physician’s order for two of the eight sampled patients (Patients 1 and 3). This failure had the potential for not providing appropriate, consistent, and quality care to thess patients. Findings: Review of Patient 1’s clinical record was initiated on 1/23/25. The clinical record showed the SOC was 6/12/24. The patient was certified for home health services during the certification period from 12/9/24 to 2/6/25. The OASIS-E1 Resumption of Care dated 1/5/25, showed the patient was on oxygen at 4 liter per minute. The SN note dated 1/6/25, showed the patient was on oxygen at 2 liters per minute. The SN note dated 1/13/25, showed the patient was on oxygen at 2 liters per minute. * However, there was no documented evidence of a physician’s order for the use of oxygen. On 1/29/25 at 0900 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS, Biller, and RN 2. They were informed and acknowledged the finding. The agency P&P titled Physician Orders revised 7/8/09, showed drugs and treatments are administered by the agency staff only as ordered by the attending physician. Such order maybe given by telephone and shall be signed by the patients attending physician and legally authorized practitioner within his or her scope of practice within 30 working days. 1. Review of Patient 3’s clinical record was initiated on 1/23/25. The clinical record showed the SOC was 6/28/24. The patient was certified for home health services during the certification periods from 10/26/24 to 12/24/24 and 12/25/24 to 2/22/25. The POC, for the certification period from 12/25/24 to 2/22/25, cited SN visits 1W1, 2W8. The POC also showed SN to assess skin breakdown every visit. SN to assess/ evaluate wound (s) at each dressing change and PRN for signs and symptoms of infection. Report to physician any significant changes. SN to perform inspection of patients’ lower extremities every visit and report any alteration in skin integrity to physician. a. Review of the SN visit notes dated 1/6/25 on the section of narrative showed the SN had performed skin assessment. The patient was assessed to have a wound to the left second toe. Cleanse the wound with normal saline, applied iodosorb covered and secured with rolled gauze and stretch netting. However, review of the clinical record failed to show documented evidenced of the physicians order for the treatment of the patients wound to the left second toe. On 1/29/25 at 0912 hours, an interview and concurrent clinical record review was conducted with the LVN Cas Manager. The LVN Case Manage was asked if there was a physicians order for the wound treatment. The LVN Case Manager replied, no MD order. The LVN Case Manager was also asked if they can perform wound care without an order. The LVN Case Manager replied, no, we should have an order. The LVN Case Manager was informed and acknowledged the finding. Findings: The agency’s P&P titled Physician Orders revised 7/8/09, showed drugs and treatments are administered by the agency staff only as ordered by the attending physician. Such order maybe given by telephone and shall be signed by the patients attending physician and legally authorized practitioner within his or her scope of practice within 30 working days. 1. Review of Patient 3’s clinical record was initiated on 1/23/25. The clinical record showed the SOC was 6/28/24. The patient was certified for home health services during the certification periods from 10/26/24 to 12/24/24 and 12/25/24 to 2/22/25. The POC, for the certification period from 12/25/24 to 2/22/25, cited SN visits 1W1 and 2W8. The POC also cited SN to assess skin breakdown every visit, assess/evaluate wound (s) at each dressing change and PRN for signs and symptoms of infection, report to the physician any significant changes, and inspection of the patient’s lower extremities every visit and report any alteration in skin integrity to the physician. Review of the SN visit notes dated 1/6/25, showed the SN had performed skin assessment showing the patient had a wound to the left second toe. The SN performed wound care as follows: cleansed the wound with normal saline, applied iodosorb (a gel to treat wet wound), and covered and secured with a rolled gauze and stretch netting. However, review of the clinical record failed to show documented evidenced of the physicians order for the treatment provided to the patient’s left second toe wound. On 1/29/25 at 0912 hours, an interview and concurrent clinical record review was conducted with the LVN Cas Manager. The LVN Case Manage was asked if there was a physicians order for the wound treatment. The LVN Case Manager replied no MD order. The LVN Case Manager was also asked if they could perform a wound care without an order. The LVN Case Manager replied no, they should have an order. The LVN Case Manager was informed and acknowledged the findings. 2. Review of Patient 1’s clinical record was initiated on 1/23/25. The clinical record showed the SOC was 6/12/24. The patient was certified for home health services during the certification period from 12/9/24 to 2/6/25. The OASIS-E1 Resumption of Care dated 1/5/25, showed the patient was on oxygen at 4 liter per minute. The SN note dated 1/6/25, showed the patient was on oxygen at 2 liters per minute. The SN note dated 1/13/25, showed the patient was on oxygen at 2 liters per minute. * However, there was no documented evidence of a physician’s order for the use of oxygen. On 1/29/25 at 0900 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS, Biller, and RN 2. They were informed and acknowledged the findings.”

“Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient’s condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This Element is not met as evidenced by: Based on observation, interview, and record review, the agency failed to revise and update the POC for two of eight sampled patients (Patients 5 and 8). This failure created the risk for not providing the necessary care and services to these patients. Findings: 1. Review of Patient 8’s clinical record was initiated on 1/27/25. The clinical record showed the SOC was 9/1/24. The patient was certified for home health services during the certification periods from 10/31/24 to 12/29/24 and 12/30/24 to 2/27/25. The physician’s order dated 12/26/24, showed Stage 1 pressure injury to both buttocks by cleaning with soap and water, apply Calmoseptine ointment (moisture barrier) daily or every diaper change. The POC, for the certification period from 12/30/24 to 2/27/25, cited SN visits 1W9 to perform assessment of patient with hypothyroidism. The patient’s medication included erythromycin ophthalmic (eye antibiotic) 5 mg/gm one cm to affected eyelid margin once at HS for two weeks. The POC showed to cleanse Stage 1 buttocks pressure injury with NS, pat dry, apply Calmoseptine ointment and leave open to air. The Medication Profile for the certification period from 12/30/24 to 2/27/25, showed a start date of 10/26/24 for erythromycin ophthalmic (eye antibiotic) 5 mg/gm one cm to affected eyelid margin once at HA for two weeks. * However, the POC was not revised to exclude the use of erythromycin ophthalmic and the POC was not revised to include the frequency of the buttocks wound treatment. On 1/29/25 at 0934 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS, Biller, and RN 2. They were informed and acknowledged the finding. 2. Review of Patient 5’s closed clinical record was initiated on 1/24/25. The clinical record showed the SOC was 12/25/24. The patient was certified for home health services during the certification periods from 12/15/24 to 2/12/25. Review of the Physicians Order dated 12/15/24, showed an order for CHHA visit 2W9. The POC, for the certification period from 12/15/24 to 2/12/25, cited CHHA visits 1W1, 2W6, 1W1. However, the POC was not revised to reflect the physicians order for CHHA visit 2W9. On 1/29/25 at 1344 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS stated the MD orders for CHHA 2W9 should have been followed, the POC was not revised to reflect the MD order. The Administrator/DPCS was informed and acknowledged the findings.”

“Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure PT services were timely for one of eight sampled patients (Patient 7). This failure created the risk of not providing quality of care and services to the patients receiving services from the HHA. Findings: The agency’s P&P titled Care Coordination Process revised 2/14/24, showed therapy services as well as medical social services when ordered will do initial evaluation 24-48 hours post receipt of referral. Review of Patient 7’s closed clinical record was initiated on 1/24/25. The closed clinical record showed the SOC was 11/14/24. The patient was certified for home health services during the certification period from 11/14/24 to 1/12/25. The POC, for the certification period from 11/14/24 to 1/12/25, cited SN visits 1W1, 2W2, and 1W6. The POC also showed PT evaluation and treatment. Documentation showed the verbal SOC was received on 11/14/24. The PT Initial Evaluation dated 11/26/24, showed the PT had conducted a visit. * However, the initial PT evaluation visit was not timely as the visit occurred 11 days after the verbal SOC was received on 11/14/24. On 1/29/25 at 0935 hours, an interview and concurrent clinical record review was conducted with the Administrative Assistant/LVN. He was informed and acknowledged the finding.”

“Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on observation, interview, and record review, the agency failed to provide a written instruction outlining the visit schedule for three of eight sampled patients (Patients 1, 2, and 3). This failure had the potential for not providing the necessary information to these patients. Findings: #. Review of Patient 1’s clinical record was initiated on 1/23/25. The clinical record showed the SOC was 6/12/24. The patient was certified for home health services during the certification period from 12/9/24 to 2/6/25. The POC, for the certification period from 12/9/24 to 2/6/25, cited SN visits 1W9 to perform assessment of patient with dementia. The physician’s order dated 1/5/25, showed SN visits daily x2, 2W2, and 1W2 for skilled assessment/observation of body systems, check vital signs, teaching/training, and follow-up. The physician’s order showed CHHA 2W5 to assist with ADLs. A joint home visit with CHHA 2 was conducted on 1/23/25 at 1016 hours, to Patient 1’s home. Review of the patient’s home folder was conducted with the RCFE Administrator and CHHA 2. However, there was no documented evidence of written instructions outlining the SN and CHHA visit schedules. On 1/29/25 at 0900 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS, Biller, and RN 2. They were informed and acknowledged the finding. #. Review of Patient 2’s clinical record was initiated on 1/27/25. The clinical record showed the SOC was 12/3/24. The patient was certified for home health services during the certification period from 12/3/24 to 1/31/25. The POC, for the certification period from 12/3/24 to 1/31/25, cited SN visits 1W9 to perform assessment of patient with hypothyroidism. The PT Evaluation dated 12/27/24, showed for the period from 12/3/24 to 1/31/25 included PT visits 1W6. A joint home visit with the PTA was conducted on 1/23/25 at 1300 hours, to Patient 2’s home. Review of the patient’s home folder was conducted with the patient. However, there was no documented evidence of written instructions outlining the SN and PT visit schedules. On 1/29/25 at 0915 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS, Biller, and RN 2. They were informed and acknowledged the finding. 1. Review of Patient 3’s clinical record was initiated on 1/23/25. The clinical record showed the SOC was 6/28/24. The patient was certified for home health services during the certification periods from 10/26/24 to 12/24/24 and 12/25/24 to 2/22/25. The POC, for the certification period from 12/25/24 to 2/22/25, cited SN visits 1W1, 2W8 for assessment of patient with Type 2 Diabetes Mellitus with foot ulcer, non pressure chronic ulcer other part, right foot with necrosis of bone, type 2diabetes mellitus with diabetic neuropathy, unspecified type 2 diabetes mellitus with diabetic chronic kidney disease, hypertensive chronic kidney disease with stage 1 to 4 unspecified chronic kidney disease, stage 3 venous insufficiency (chronic) (peripheral), other atherosclerotic native arteries of extremities, right leg, other specified arthritis, multiple sites contracture, right knee. The POC also showed SN to assess skin breakdown every visit. SN to assess/ evaluate wound (s) at each dressing change and PRN for signs and symptoms of infection. Report to physician any significant changes. SN to perform inspection of patients’ lower extremities every visit and report any alteration in skin integrity to physician. A joint home visit with LVN 1 was conducted on 1/23/25 at 1000 hours, to Patient 3’s home. Review of the patient’s home folder was conducted with LVN 1. However, there was no documented evidence of written instructions outlining the SN visit schedules. On 1/23/25 at 1127 hours, an interview and concurrent document review was conducted with the LVN 1. LVN 1 was asked if a visit schedule was available in the home folder. The LVN 1 replied, no. The LVN 1 was also asked if she uses a visit calendar. The LVN 1 replied, no, I don’t use it. The LVN 1 was informed and acknowledged the finding. On 1/29/25 at 0940 hours, the finding was shared with the LVN Case Manager. The LVN Case Manager acknowledged the finding. 1. Review of Patient 3’s clinical record was initiated on 1/23/25. The clinical record showed the SOC was 6/28/24. The patient was certified for home health services during the certification periods from 10/26/24 to 12/24/24 and 12/25/24 to 2/22/25. The POC, for the certification period from 12/25/24 to 2/22/25, cited SN visits 1W1 and 2W8 for assessment of the patient with Type 2 Diabetes Mellitus with foot ulcer, non pressure chronic ulcer other part, right foot with necrosis of bone, type 2diabetes mellitus with diabetic neuropathy, unspecified type 2 diabetes mellitus with diabetic chronic kidney disease, hypertensive chronic kidney disease with stage 1 to 4 unspecified chronic kidney disease, stage 3 venous insufficiency (chronic) (peripheral), other atherosclerotic native arteries of extremities, right leg, other specified arthritis, and multiple sites contracture, right knee. The POC also showed SN to assess skin breakdown every visit and assess/evaluate wounds at each dressing change and PRN for signs and symptoms of infection, report to the physician any significant changes, perform inspection of the patients’ lower extremities every visit, and report any alteration in skin integrity to the physician. A joint home visit with LVN 1 was conducted on 1/23/25 at 1000 hours, to Patient 3’s home. Review of the patient’s home folder was conducted with LVN 1. However, there was no documented evidence of written instructions outlining the SN visit schedules. On 1/23/25 at 1127 hours, an interview and concurrent document review was conducted with LVN 1. LVN 1 was asked if a visit schedule was available in the home folder. LVN 1 replied, no. LVN 1 was also asked if she used a visit calendar. LVN 1 replied no. LVN 1 was informed and acknowledged the finding. On 1/29/25 at 0940 hours, the finding was shared with the LVN Case Manager. The LVN Case Manager acknowledged the finding. 2. Review of Patient 1’s clinical record was initiated on 1/23/25. The clinical record showed the SOC was 6/12/24. The patient was certified for home health services during the certification period from 12/9/24 to 2/6/25. The POC, for the certification period from 12/9/24 to 2/6/25, cited SN visits 1W9 to perform assessment of the patient with dementia. The physician’s order dated 1/5/25, showed SN visits daily x2, 2W2, and 1W2 for skilled assessment/observation of body systems, checking vital signs, teaching/training, and follow-up. The physician’s order showed CHHA 2W5 to assist with ADL cares. A joint home visit with CHHA 2 was conducted on 1/23/25 at 1016 hours, to Patient 1’s home. Review of the patient’s home folder was conducted with the RCFE Administrator and CHHA 2. However, there was no documented evidence of written instructions outlining the SN and CHHA visit schedules. On 1/29/25 at 0900 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS, Biller, and RN 2. They were informed and acknowledged the finding. 3. Review of Patient 2’s clinical record was initiated on 1/27/25. The clinical record showed the SOC was 12/3/24. The patient was certified for home health services during the certification period from 12/3/24 to 1/31/25. The POC, for the certification period from 12/3/24 to 1/31/25, cited SN visits 1W9 to perform assessment of the patient with hypothyroidism. The PT Evaluation dated 12/27/24, showed for the period from 12/3/24 to 1/31/25, to provide PT visits 1W6. A joint home visit with the PTA was conducted on 1/23/25 at 1300 hours, to Patient 2’s home. Review of the patient’s home folder was conducted with the patient. However, there was no documented evidence of written instructions outlining the SN and PT visit schedules. On 1/29/25 at 0915 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS, Biller, and RN 2. They were informed and acknowledged the findings.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on observation, interview, and record review, the agency failed to ensure the patients received care and services as per the written plan of care for five of eight sampled patients (Patients 3, 4, 5, 6, and 8). This failure had the potential for not providing appropriate, consistent, and quality care to these patients. #. Review of Patient 8’s clinical record was initiated on 1/27/25. The clinical record showed the SOC was 9/1/24. The patient was certified for home health services during the certification periods from 10/31/24 to 12/29/24 and 12/30/24 to 2/27/25. The POC, for the certification period from 12/30/24 to 2/27/25, cited SN visits 1W9 to perform assessment of patient with hypothyroidism. The POC showed to cleanse Stage 1 buttocks pressure injury with NS, apt dry, apply Calmoseptine (moisture barrier) ointment and leave open to air. The SN note dated 12/31/24, 1/3, 1/7, and 1/10/25, showed SN provided treatment to Stage 1 buttocks pressure injury. Documentation showed cleansed with NS, patted dry with gauze, applied A&D cream (moisture barrier) and Calmoseptine on the redness area, which was not consistent with the POC. On 1/29/25 at 0934 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS, Biller, and RN 2. They were informed and acknowledged the finding. #. Review of Patient 4’s clinical record was initiated on 1/23/25. The clinical record showed the SOC was 8/2/24. The patient was certified for home health services during the certification periods from 10/1/24 to 11/29/24 and 11/30/24 to 1/28/25. The POC, for the certification period from 11/30/24 to 1/28/25, cited SN visits 2W2 and 1W6. Documentation showed to notify the physician if pulse is greater than 100 or less than 60 and the systolic BP greater than 160 mm Hg or less than 90 mm Hg. The SN note dated 12/22/24, showed the patient’s pulse was 59 and the BP was 164/85 mm Hg. * However, there was no documented evidence the physician was notified regarding the patient’s pulse less than 60 and systolic BP greater than 160 mm Hg. On 1/29/25 at 0905 hours, an interview and concurrent clinical record review was conducted with the Administrative Assistant/LVN. He was informed and acknowledged the finding. 1. Review of Patient 3’s clinical record was initiated on 1/23/25. The clinical record showed the SOC was 6/28/24. The patient was certified for home health services during the certification periods from 10/26/24 to 12/24/24 and 12/25/24 to 2/22/25. The POC, for the certification period from 12/25/24 to 2/22/25, cited SN visits 1W1, 2W8. The POC showed SN to assess skin breakdown every visit. SN to assess/ evaluate wound (s) at each dressing change and PRN for signs and symptoms of infection. The wound care includes to leave adaptic and steri-strip in place. Change outer dressings only. SN to cover adaptic with abdominal pad, secure with rolled gauze and tape. Change on Friday and Monday. Report to physician any significant changes. SN to perform inspection of patients’ lower extremities every visit and report any alteration in skin integrity to physician. * Review of the SN visit notes dated 1/6/25 on the section of narrative showed the SN had performed wound assessment and treatment. The patient was assessed to have a wound to the left second toe. However, review of the clinical record failed to show documented evidenced of the physician was notified of the wound on the patients left second toe as ordered in the POC. * Review of the SN visit notes dated 1/1, 1/6, 1/10, 1/13, 1/17 and 1/20/25, showed the SN had performed wound treatment to the patients right forefoot. However, the SN failed to performed wound assessments every visit as ordered in the POC. On 1/29/25 at 0912 hours, an interview and concurrent clinical record review was conducted with the LVN Case Manager. The LVN Case Manager was informed and acknowledged the findings. Cross ref. G- 984 b. The POC, for the certification period from 10/26/24 to 12/24/24, cited SN visits 2W9. The POC showed SN to assess skin breakdown every visit. SN to assess/ evaluate wound (s) at each dressing change and PRN for signs and symptoms of infection. The wound care includes cleanse the right forefoot wound with normal saline solution, pat dry, apply Prisma into superior hole, then Endoform on wound bed, wrap with rolled gauze, change on Monday and Friday. Report to physician any significant changes. SN to perform inspection of patients’ lower extremities every visit and report any alteration in skin integrity to physician. The POC also showed to to notify physician for the systolic BP greater than 160 or less than 90, diastolic BP greater than 90 or less than 60 and oxygen saturation less than 90. Review of the SN visit notes dated 10/28, 11/4, 11/11, 11/28, 11/25, 12/2, 12/9 and 12/16/24 showed the SN had performed body system assessment and wound dressing change to the patients right forefoot. However, the SN failed to performed wound assessment the patients right forefoot as ordered in the POC. * Review of the SN notes dated 11/9 and 12/6/24, showed the SN had performed vital signs assessment. The vital signs showed a BP reading of 178/77 sitting. However, review of the clinical record failed to show documented evidenced of the physician was notified of the elevated BP as ordered in the POC. In addition, review of the SN notes dated 11/1/24, showed the SN had performed vital signs assessment. However, the oxygen saturation was left blank. On 1/29/25 at 0947 hours, an interview and concurrent clinical record review was conducted with the LVN Case Manager. The LVN Case Manager was informed and acknowledged the findings. 2. Review of Patient 6’s closed clinical record was initiated on 1/27/25. The clinical record showed the referral date was 2/24/23, and the patient’s OASIS SOC was 3/2/23. The patient was certified for home health services during the certification periods from 8/29/23 to 10/27/23 and 10/28/23 to 12/26/23. The patient was discharged from the HHA on 11/24/23. a. The POC, for the certification period from 10/28/23 to 12/26/23, cited SN visits 1W9. The POC showed SN to assess patient with unspecified dementia, unspecified severity without behavior/psychiatric/mood/anxiety, hypotension, unspecified exocrine pancreatic insufficiency, vitamin B12 anemia, unspecified, vitamin D deficiency, and unspecified urge incontinence. The POC includes SN to check vital signs every visit and notify physician if the oxygen saturation less than 90%. The POC also includes SN to assess for changes in neurological status every visit. Review of the SN notes dated 11/4 and 11/18/23, showed the SN had performed neurological assessment. However, the section for the orientation to person, place and time was left blank. Further review of the SN visit notes dated 11/4, 11/11 and 11/1/23, showed the SN had performed vital signs assessment. However, the section for the oxygen saturation was left blank. On 1/29/25 at 1018 hours, an interview and concurrent clinical record review was conducted with the LVN Case Manager. The LVN Case Manager was informed and acknowledged the findings. b. The POC, for the certification period from 8/29/23 to 10/27/23, cited SN visits 1W9. The POC showed SN to assess patient with exocrine pancreatic insufficiency, vitamin B12 deficiency anemia, unspecified, hypertensive heart disease without heart failure, unspecified dementia, unspecified severity, without behavior/psychiatric/mood/anxiety, vitamin D deficiency, unspecified low back pain and unspecified urge incontinence. The POC includes SN to check vital signs every visit and notify physician if the oxygen saturation less than 90%. The POC also includes SN to assess for changes in neurological status every visit. Review of the SN notes dated 9/2, 9/9, 9/16, 9/23, 9/30, 10/7, 10/14 and 10/21/23 showed the SN had performed neurological assessment. However, the section for the orientation to person, place and time was left blank. Further review of the SN visit notes dated 9/2, 9/9, 9/16, 9/23, 9/30, 10/7, 10/14 and 10/21/23, showed the SN had performed vital signs assessment. However, the section for the oxygen saturation was left blank. On 1/29/25 at 1007 hours, an interview and concurrent clinical record review was conducted with the LVN Case Manager. The LVN Case Manager was informed and acknowledged the findings. 3. Review of Patient 5’s closed clinical record was initiated on 1/24/25. The clinical record showed the SOC was 12/25/24. The patient was certified for home health services during the certification periods from 12/15/24 to 2/12/25. a. The POC, for the certification period from 12/15/24 to 2/12/25, cited SN visits 2W2, 1W7 for assessment of patient with Type 2 Diabetes Mellitus with diabetic neuropathy, unspecified cervical disc disorder with myelopathy, unspecified cervical region, paroxysmal atrial fibrillation, multiple myeloma not having achieve remission, mixed hyperlipidemia, gastro - esophageal reflux disease without esophagitis, essential (primary) hypertension, muscle wasting and atrophy, NEC multiple sites, slow transit, constipation, vitamin B12 deficiency anemia, unspecified. The POC includes SN to assess pain level and effectiveness of pain medications and current pain management therapy every visit. Review of the SN notes dated 12/20/24, 1/23, 12/28/24, 1/6/25, 1/13 and 1/20/25 showed the SN had performed pain assessment. The assessment showed the following: - frequency of pain interfering with patient’s activity or movement = less often than daily, - the primary site = neck, - pain intensity = 3, - current pain management and effectiveness was blank and - what makes the pain worse = moving. However, the SN failed to assess the patients current pain medication and effectiveness every visit as the section was left blank. b. The POC, for the certification period from 12/15/24 to 2/12/25, cited PT for strengthening and safety. Review of the Physicians Order dated 12/18/24, showed an order for PT to evaluate/ instruct/perform home safety, therapeutic exercises, ROM exercises, strengthening exercises, gait training, balance drills, transfers training and set up home exercise program. PT visits 1W2, 2W5. Review of the clinical record showed the PT performed an evaluation on Week 1 (from 12/15 to 12/21/24) on 12/18/24. However, review of the clinical record failed to show documented evidenced of the PT visits on Week 2 (from 12/22 to 12/28/24) as per physicians order. On 1/29/25 at 0935 an interview and concurrent clinical record review was conducted with the Administrative Assistant/LVN. The Administrative Assistant/LVN was informed and acknowledged the findings.”

“Patient and caregiver education CFR(s): 484.75(b)(5) Patient and caregiver education; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patient and or caregiver was provided education related to anticoagulant medication and oxygen therapy as per the plan of care for one of eight sampled patients (Patient 5). This failure had the potential for not providing the necessary care and services to these patients. Findings: Review of Patient 1’s clinical record was initiated on 1/23/25. The clinical record showed the SOC was 6/12/24. The patient was certified for home health services during the certification period from 12/9/24 to 2/6/25. The OASIS-E1 Resumption of Care dated 1/5/25, instructed PCG on flu precautions and oxygen therapy and management. The SN note dated 1/6/25, showed teaching done on how to care for patient with oxygen. However, there was no documented evidence the POC included patient/PCG education on oxygen therapy and management. On 1/29/25 at 0900 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS, Biller, and RN 2. They were informed and acknowledged the finding. 1. Review of Patient 5’s closed clinical record was initiated on 1/24/25. The clinical record showed the SOC was 12/25/24. The patient was certified for home health services during the certification periods from 12/15/24 to 2/12/25. The POC, for the certification period from 12/15/24 to 2/12/25, cited SN visits 2W2, 1W7 for assessment of patient with Type 2 Diabetes Mellitus with diabetic neuropathy, unspecified cervical disc disorder with myelopathy, unspecified cervical region, paroxysmal atrial fibrillation, multiple myeloma not having achieve remission, mixed hyperlipidemia, gastro - esophageal reflux disease without esophagitis, essential (primary) hypertension, muscle wasting and atrophy, NEC multiple sites, slow transit, constipation, vitamin B12 deficiency anemia, unspecified. The POC includes SN to instruct the patient/caregiver on precautions for high risk medications to anticoagulants/anti-platelets. The Medication Profile for the certification period from 12/15/24 to 2/12/25, showed the patient’s medications included Eliquis (anticoagulant) 5 mg one tablet PO BID. Review of the SN notes dated 12/20/24, 1/23, 12/28/24, 1/6/25, 1/13 and 1/20/25 showed the SN had performed body system assessment. However, review of the SN visit notes failed to show documented evidenced of the patient/PCG education related to the use of Eliquis (anticoagulant) was provided as instructed in the POC. On 1/29/25 at 0935 hours, an interview and concurrent clinical record review was conducted with the Administrative Assistant/LVN. The Administrative Assistant/LVN was asked if there was an education related to anticoagulant use. The Administrative Assistant/LVN replied, the precautions were not discussed on the SN visit notes. The Administrative Assistant/LVN was informed and acknowledged the finding. Findings: 1. Review of Patient 5’s closed clinical record was initiated on 1/24/25. The clinical record showed the SOC was 12/25/24. The patient was certified for home health services during the certification periods from 12/15/24 to 2/12/25. The POC, for the certification period from 12/15/24 to 2/12/25, cited SN visits 2W2 and1W7 for assessment of the patient. The POC included SN to instruct the patient/caregiver on precautions for high risk medications to anticoagulants/antiplatelets. The Medication Profile for the certification period from 12/15/24 to 2/12/25, showed the patient’s medications included Eliquis (anticoagulant) 5 mg one tablet PO BID. Review of the SN notes dated 12/20/24, 1/23, 12/28/24, 1/6/25, 1/13, and 1/20/25, showed the SN had performed body system assessment. However, review of the SN visit notes failed to show documented evidence of the education related to the use of Eliquis (anticoagulant) was provided to the patient/PCG as instructed in the POC. On 1/29/25 at 0935 hours, an interview and concurrent clinical record review was conducted with the Administrative Assistant/LVN. The Administrative Assistant/LVN was asked if there was an education related to anticoagulant use. The Administrative Assistant/LVN stated the precautions were not discussed on the SN visit notes. The Administrative Assistant/LVN was informed and acknowledged the finding. 2. Review of Patient 1’s clinical record was initiated on 1/23/25. The clinical record showed the SOC was 6/12/24. The patient was certified for home health services during the certification period from 12/9/24 to 2/6/25. The OASIS-E1 Resumption of Care dated 1/5/25, showed the SN instructed PCG on flu precautions and oxygen therapy and management. The SN note dated 1/6/25, showed teaching was done on how to care for the patient with oxygen. However, there was no documented evidence the POC included the patient/PCG education on oxygen therapy and management. On 1/29/25 at 0900 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS, Biller, and RN 2. They were informed and acknowledged the finding.”

“Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure the agency’s skilled professionals prepared accurate clinical notes for seven of eight sampled patients (Patients 1, 2, 3, 5, 6, 7, and 8). This failure had the potential for substandard healthcare outcomes to these patients. #. Review of Patient 1’s clinical record was initiated on 1/23/25. The clinical record showed the SOC was 6/12/24. The patient was certified for home health services during the certification period from 12/9/24 to 2/6/25. The Physician’s Order dated 1/5/25, showed SN visits daily x2, 2W2, and 1W2 for skilled assessment/observation of body systems, check vital signs, teaching/training, and follow-up. The physician’s order included pureed diet. The SN note dated 1/6/25, showed renal heart healthy pureed diet. The SN note dated 1/13/25, showed renal diet. * However, the diet in the physician’s order was not consistent with the SN notes dated 1/6 and 1/13/25. On 1/29/25 at 0900 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS, Biller, and RN 2. They were informed and acknowledged the finding. #. Review of Patient 2’s clinical record was initiated on 1/27/25. The clinical record showed the SOC was 12/3/24. The patient was certified for home health services during the certification period from 12/3/24 to 1/31/25. The POC, for the certification period from 12/3/24 to 1/31/25, cited SN visits 1W9 to perform assessment of patient with hypothyroidism. The POC included to administer D5 NS 500 ml/one hour for two hours via peripheral line once a month for one year as directed by the physician. The OASIS-E Start of Care dated 12/3/24, showed D5 1/2 NS one liter was started to run for two hours. The SN note dated 1/3/25, showed D5 1/2 NS one liter was started and completed after two hours. The Delivery Ticket from the pharmacy dated 12/2/24 and 12/30/24, showed D5 NS was delivered. On 1/29/25 at 0915 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS, Biller, and RN 2. The Administrator/DPCS stated the RN did not administer D5 1/2 NS. They were informed and acknowledged the finding. * However, the information of the intravenous fluid concentration was not accurately documented in the SN notes dated 12/3/24 and 1/3/25. #. Review of Patient 8’s clinical record was initiated on 1/27/25. The clinical record showed the SOC was 9/1/24. The patient was certified for home health services during the certification periods from 10/31/24 to 12/29/24 and 12/30/24 to 2/27/25. The OASIS-E Recertification dated 12/26/24, showed the patient had a Stage 1 right and left buttock pressure injury. The POC, for the certification period from 12/30/24 to 2/27/25, cited SN visits 1W9 to perform assessment of patient with hypothyroidism. The POC showed to cleanse Stage 1 buttocks pressure injury with NS, apt dry, apply Calmoseptine (moisture barrier) ointment and leave open to air. There was no documented evidence the patient’s Stage 1 right and left buttock pressure injury was measured on Week 3 (1/12/25 to 1/18/25). On 1/29/25 at 0934 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS, Biller, and RN 2. RN 2 stated the patient’s Stage 1 right and left buttock pressure injury was healed on Week 3. * However, RN 2 failed to document the patient’s Stage 1 right and left buttock pressure injury was healed on Week 3 On 1/29/25 at 0934 hours, the Administrator/DPCS, Biller, and RN 2 were informed and acknowledged the finding. #. Review of Patient 7’s closed clinical record was initiated on 1/24/25. The closed clinical record showed the SOC was 11/14/24. The patient was certified for home health services during the certification period from 11/14/24 to 1/12/25. The POC, for the certification period from 11/14/24 to 1/12/25, showed the patient’s nutritional requirements included no added salt mechanical soft heart healthy. The SN note dated 11/20, 11/22, and 11/27/24, showed regular diet, which was not consistent with the POC. On 1/29/25 at 0935 hours, an interview and concurrent clinical record review was conducted with the Administrative Assistant/LVN. He was informed and acknowledged the finding. 1. Review of Patient 3’s clinical record was initiated on 1/23/25. The clinical record showed the SOC was 6/28/24. The patient was certified for home health services during the certification periods from 10/26/24 to 12/24/24 and 12/25/24 to 2/22/25. The POC, for the certification period from 10/26/24 to 12/24/24, cited SN visits 2W9 for assessment of patient with Type 2 Diabetes Mellitus with foot ulcer, non pressure chronic ulcer other part, right foot with necrosis of bone, type 2diabetes mellitus with diabetic neuropathy, unspecified type 2 diabetes mellitus with diabetic chronic kidney disease, hypertensive chronic kidney disease with stage 1 to 4 unspecified chronic kidney disease, stage 3 venous insufficiency (chronic) (peripheral), other atherosclerotic native arteries of extremities, right leg, other specified arthritis, multiple sites contracture, right knee. The POC includes SN to assess blood sugar via finger stick every visit prior to insulin administration. The POC also includes to notify physician for fasting blood sugar greater than 300 or less than 60, random blood sugar greater than 300 or less than 60 and diastolic BP greater than 160 or less than 90 and systolic BP greater than 90 or less than 60. a. Review of the SN notes showed the SN had assess the patients blood sugar level on the following dates: -On 12/9 - blood sugar was 91, -On 12/13 - blood sugar was 127 and -On 12/16/24 - Blood sugar was 118. However, on the narrative section of the notes showed patient was not able to check her blood sugar but refused for SN to check the patients blood sugar which was inconsistent. b. Review of the SN notes showed the SN had assess the patients blood pressure on the following dates: -On 12/2 - BP was 120/60, -On12/9 - BP was 130/60, -On 12/13 - BP was 112/60 and -On 12/16/24 - BP was 130/80. However, on the narrative section of the notes showed patient was documented as 178/77which was inconsistent. On 1/29/25 at 0947 hours, an interview and concurrent clinical record review was conducted with the LVN Case Manager. The LVN Case Manager was informed and acknowledged the findings. 2. Review of Patient 6’s closed clinical record was initiated on 1/27/25. The clinical record showed the SOC was 3/2/23. The patient was certified for home health services during the certification periods from 8/29/23 to 10/27/23 and 10/28/23 to 12/26/23. The CHHA Care Plan dated 8/26/23 for the certification periods from 8/29/23 to 10/27/23, showed for the CHHA vital signs notification parameters. The vital signs parameters includes the following for pulse and respiration: - pulse - more than 24 and less than 12 and - respiration - more than 100 and less than 60. However, the parameters for pulse rate and respiratory rate were inaccurate. In addition, review of the CHHA visit notes dated 8/29, 9/2, 9/5, 9/8, 9/12, 9/19, 9/22, 9/26, 10/3, 10/6, 10/10, 10/10, 10/13, 10/17,10/20,10/24 and 10/27/23, showed the CHHA check the vital signs. However, the physician notifications for the pulse and respiratory rate parameters were inaccurate. On 1/29/25 at 1007, an interview and concurrent clinical record review was conducted with the LVN Case Manager. The LVN Case Manager was informed and acknowledged the findings. 3. Review of Patient 5’s closed clinical record was initiated on 1/24/25. The clinical record showed the SOC was 12/25/24. The patient was certified for home health services during the certification periods from 12/15/24 to 2/12/25. The POC, for the certification period from 12/15/24 to 2/12/25, cited SN visits 2W2, 1W7 for assessment of patient with Type 2 Diabetes Mellitus with diabetic neuropathy, unspecified cervical disc disorder with myelopathy, unspecified cervical region, paroxysmal atrial fibrillation, multiple myeloma not having achieve remission, mixed hyperlipidemia, gastro - esophageal reflux disease without esophagitis, essential (primary) hypertension, muscle wasting and atrophy, NEC multiple sites, slow transit, constipation, vitamin B12 deficiency anemia, unspecified. The POC also includes SN to assess pain level and effectiveness of pain medications and current pain management therapy every visit. a. Review of the SN notes dated 12/20/24, 1/13/25 showed the SN had performed pain assessment. The assessment showed the following: - frequency of pain interfering with patient’s activity or movement = less often than daily, - the primary site = neck, - pain intensity = 3, - current pain management and effectiveness was blank and - what makes the pain worse = moving. However, on the section of the narrative notes showed the SN documented patient denies pain and discomfort at this time which was inconsistent. b. Review of SN notes dated 12/28, 1/20/25 showed the SN had performed cardiovascular assessment. The assessment includes a check marked on the section of WNL (within normal limits) and on the section of edema. The edema was located on bilateral lower extremity, 2+. However, on the section of narrative notes showed the SN documented no swelling noted which was inconsistent. On 1/29/25 at 0935 an interview and concurrent clinical record review was conducted with the Administrative Assistant/LVN. The Administrative Assistant/LVN was informed and acknowledged the findings.”

“Nursing services supervised by RN CFR(s): 484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k). This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure the HHA’s RN provided supervision to the LVN to ensure quality of care and services were provided for one of eight sampled patients (Patient 8). This failure had the potential for substandard health outcomes to this patient. Review of Patient 8’s clinical record was initiated on 1/27/25. The clinical record showed the SOC was 9/1/24. The patient was certified for home health services during the certification periods from 10/31/24 to 12/29/24 and 12/30/24 to 2/27/25. Review of the clinical record for Patient 8 showed the LVN did not provide services in accordance with the POC for this patient. Cross reference to G710, example #4. The LVN Supervisory Note dated 1/22/25, showed the RN had conducted a supervisory visit and the LVN followed the plan of care. * However, the RN failed to identify the LVN did not provide services in accordance with the POC. On 1/29/25 at 0934 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS, Biller, and RN 2. They were informed and acknowledged the finding.”

“Documentation of inservice training CFR(s): 484.80(d)(2) The HHA must maintain documentation that demonstrates the requirements of this standard have been met. This Element is not met as evidenced by: Based on interview and record review, the agency’s Administrator failed to be responsible for the day-to-day operations related to CHHA in-service training documentation. This failure had the potential for not providing quality of care and services to the patients receiving services from the HHA. Review of the Job Description for the agency’s Administrator signed and dated 6/10/24, showed the performance, responsibilities and standards includes to ensure quality and safe delivery of services such as developed and implemented written agency policy and procedures reflect safety and quality delivery of home health services. The agency’s P&P titled In- Service Training, undated, showed the agency provides continuous in-service training program for all employees. The purpose was to provide employee competence, improve patient care and to improve employee efficiency. The procedures includes the documentation of attendance in in-service training session, and or completion of in-service training exercises is retained in the in-service training files with cross filing in the personnel record of the individual staff participating. Review of the agency’s binder for CHHA 2024 In-service was initiated on 1/28/25. The binder showed the in-services and the post test trainings provided to the CHHA’s monthly. The binder also included the staff attendance form. The attendance form showed the agency had 4 CHHAs. However, the training exercises for the months of January, February, March, April, May, June, July and August 2024 were left blank. In addition, there were no documented evidenced of the training exercises provided for the month of October and December 2024 as per the agency’s P&P. On 1/19/25 at 0900 hours, an interview and concurrent document review was conducted with the LVN Case Manager. The LVN Case Manager was informed and acknowledged the findings.”

“Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This Element is not met as evidenced by: Based on observation, interview, and record review, the agency failed to ensure care and services were provided in accordance with the care plan for two of eight sampled patients (Patient 5 and 6). This failure had the potential for not providing appropriate, consistent, and quality care to these patients. 1. Review of Patient 6’s closed clinical record was initiated on 1/27/25. The clinical record showed the SOC was 3/2/23. The patient was certified for home health services during the certification periods from 8/29/23 to 10/27/23 and 10/28/23 to 12/26/23. The Aide Care Plan dated 8/26/23, for the certification periods from 8/29/23 to 10/27/23, cited CHHA 2W9. The Aide Care plan showed the assignment for the CHHA every visit. The assignment includes functional limitations, DME, supplies, activities permitted, elimination, household, personal care, vital sign notification and vital signs every visit. Review of the CHHA visit notes dated 9/29/23, showed the CHHA performed the care plan assignment. However, the section for vital signs - blood pressure, temperature, pulse and respiration were left blank. On 1/29/25 at 1007 hours, an interview and concurrent clinical record review was conducted with the LVN Case Manager. The LVN Case Manager was informed and acknowledged the finding. 2. Review of Patient 5’s closed clinical record was initiated on 1/24/25. The clinical record showed the SOC was 12/25/24. The patient was certified for home health services during the certification periods from 12/15/24 to 2/12/25. The POC, for the certification period from 12/15/24 to 2/12/25, cited CHHA 1W1, 2W6, and 1W1 for assistance with ADL/IADL cares. Review of the Aide Care Plan dated 12/15/24, cited CHHA visit 2W9 for the assessment of functional limitations, vital sign notification to include no bowel movement in 3 days, vital signs, activity for ambulation and transfer and personal care every visit. However, review of the clinical record failed to show documented evidence of the CHHA visits during Week 2 (from 12/22 to 12/28/24) as cited in the POC. On 1/29/25 at 0935 hours, an interview and concurrent clinical record review was conducted with the Administrative Assistant/LVN. The Administrative Assistant/LVN was informed and acknowledged the findings. On1/29/25 at 1344 hours, a follow -up interview and concurrent clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS stated the patient refused a CHHA visit during the first two weeks; however, there was no documentation found in the clinical record. The Administrator/DPCS was informed and acknowledged the findings.”

“Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the agency’s RN provided the onsite supervision for the CHHA no less frequently than every 14 days to ensure quality of care and services provided for one of eight sampled patients (Patient 6). This failure had the potential for substandard health outcomes to this patient. The agency’s P&P titled Home Health Aide Services, undated, showed the procedures includes the registered nurse makes a supervisory visit to the patients residence at least every two weeks following the policy and procedure. Review of Patient 6’s closed clinical record was initiated on 1/27/25. The clinical record showed the SOC was 3/2/23. The patient was certified for home health services during the certification periods from 8/29/23 to 10/27/23 and 10/28/23 to 12/26/23. The POC, for the certification period from 10/28/23 to 12/26/23, showed CHHA visits 2W9. Review of the CHHA notes dated 10/31, 11/3, 11/6, 11/10, 11/14, and 11/21/23, showed the CHHA provided care and services as ordered. However, there was no documented evidence the agency’s RN provided supervision to the CHHA no less frequently than every 14 days. On 1/29/25 at 1018 hours, an interview and concurrent closed clinical record review was conducted with the LVN Case Manager. The LVN Case Manager was asked about the frequency of the supervisory visit for the CHHA. The LVN Case Manager stated the supervisory visit was conducted every two weeks. The LVN Case Manager was also asked when the supervisory visit should be conducted. The LVN Case Manager replied they should be on 11/1 and 11/15/23, but we missed two supervisory visits. The LVN Case Manager was informed and acknowledged the findings.”

“Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This Element is not met as evidenced by: Based on interview and record review, the agency’s Administrator failed to be responsible for the day-to-day operations related to the written agreements with the contracted RD, PT, and OT. This failure had the potential for not providing quality of care and services to the patients receiving services from the HHA. The agency’s Job Description for Administrator dated 6/10/24, showed the performance responsibilities and standards included ensuring compliance of agency operations with federal, state, and local rules and regulations. Title 22 Section 74719 (Services Arranged by Agreement), showed the following: (b) The agreement shall include at least the following: (1) The nature and scope of the services to be provided; (2) The rights and responsibilities of the agency or individual providing services and of the contracting agency in the coordination, supervision, and evaluation of the care or services provided; (3) The role, if any, of the agency and the contracted individual or agency in: (A) The patient admission process, (B) Patient assessment, (C) The development, review, and revision of the plan of treatment or plan of care, (D) Patient care conferences, (E) The scheduling of visits or hours, (F) Discharge planning; (4) The submission to the agency of documentation of services provided; (5) The responsibility of the contracted individual or agency to adhere to applicable agency policies, including personnel qualifications; (6) The procedures for determining charges and reimbursement; and (7) The term of the agreement and the conditions for its renewal or termination. (c) Agreements shall be reviewed and revised as necessary. 1. Review of the written agreements between the agency and contracted RD was initiated on 1/28/25. The agency’s written agreement with the contracted RD did not include the role of the agency and contracted RD for the patient admission process, scheduling of visits or hours, discharge planning, the submission to the agency of documentation of services provided. 2. Review of the written agreements between the agency and contracted PT and OT was initiated on 1/28/25. The agency’s written agreement with the contracted PT and OT did not include the role of the agency and the contracted PT and OT for the patient admission process, patient care conferences, and discharge planning. On 1/29/25 at 1011 hours, an interview and concurrent record review was conducted with the Administrator/DPCS. She was informed and acknowledged the findings.”

“In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure the agency’s P&Ps were implemented related to the following: No discharge summary sent to the physician within five business days for one of eight sampled patients (Patient 6). The performance evaluation and skills competency were not completed for CHHA 3. The pre-employment health screening and hepatitis B Vaccine were not in the personnel files for CHHAs 1 and 3 and LVNs 1 and 3. Wound assessments were not performed for Patients 3 and 8 as per the agency’s P&P. These failures created the risk of not providing quality of care and services to the patients receiving services from the HHA. #. Review of Patient 8’s clinical record was initiated on 1/27/25. The clinical record showed the SOC was 9/1/24. The patient was certified for home health services during the certification periods from 10/31/24 to 12/29/24 and 12/30/24 to 2/27/25. The OASIS-E Recertification dated 12/26/24, showed the patient had a Stage 1 right and left buttock pressure injury. The POC, for the certification period from 12/30/24 to 2/27/25, cited SN visits 1W9 to perform assessment of patient with hypothyroidism. The POC showed to cleanse Stage 1 buttocks pressure injury with NS, apt dry, apply Calmoseptine (moisture barrier) ointment and leave open to air. * However, there was no documented evidence the patient’s Stage 1 right and left buttock pressure injuries were measure on Week 1 (12/30/24 to 1/4/25) and Week 2 (1/5/25 to 1/11/25). On 1/29/25 at 0934 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS, Biller, and RN 2. They were informed and acknowledged the finding. 1. The agency’s P&P titled Discharge Summary reviewed 10/29/06, showed a discharge summary will be completed within seven days of the discharge date. The purpose includes to document instructions given to the client/family regarding medications. The procedure includes a copy will be sent to the physician upon request for example: Review of Patient 6’s closed clinical record was initiated on 1/27/25. The clinical record showed the referral date was 2/24/23, and the patient’s OASIS SOC was 3/2/23. The patient was certified for home health services during the certification periods from 8/29/23 to 10/27/23 and 10/28/23 to 12/26/23. The patient was discharged from the HHA on 11/24/23. However, the agency’s P&P failed to indicate the timeline of the discharge summary needed to be sent to the physician within five business days from discharge as per state regulation. On 1/29/25 at 1018 hours, an interview and concurrent clinical record review was conducted with the LVN Case Manager. The LVN Casa Manager was asked if the discharge summary was sent to the physician within 5 business days from discharge. The LVN Case Manager reviewed their files and replied, no documentation as to when the discharge summary was sent to the physician. The LVN Case Manager was also asked if the policy was updated to reflect the timeline of 5 business days from discharge to be sent to the physician. The LVN/Case Manager replied, no, we need to update our P&P. The LVN Case Manager was informed and acknowledged the finding. cross ref. G - 1022 2. Review of the agency’s P&P showed the following were not implemented: a. The agency’s P&P titled Health Screening revised 11/11/09, showed the purpose was to ensure safe health status of each worker to perform essential job functions. The procedure included a pre-employment physical examination will be performed by physician or nurse practitioner as mandated by state, federal and local laws. Health screening will occur after a conditional offer of employment is made within six months prior to employment or within 15 days of assuming employment). A complete physical examination will be required at least every two years. The written physical examination shall be signed by the person who performed the assessment, verify that employee is free from health conditions which would interfere with the employees ability to performed assigned duties, contained verification that the employee is free from signs and symptoms of infectious disease and provide for a tuberculosis screening which shall be administered to all employees who have direct patient contact and annually thereafter using 5 TU (Tuberculin units) Protein Derivative (PPD) tuberculin skin test. Hepatitis B Vaccine and vaccination series shall be made available to all employees who are at risk for exposure to blood and body fluids. Acceptance or refusal of the vaccine must be documented. * Review of the CHHA 3’s personnel file showed the hiring date was 9/22/17. The employee’s latest physical examination was dated 7/13/22 and 9/20/22. However, there was no documented evidence of the physical examination was conducted after two years as per agency’s P&P. On 1/29/25 at 1035 hours, an interview and concurrent document review was conducted with the Administrative Assistant/LVN. The Administrative Assistant/LVN was informed and acknowledged the findings. * Review of LVN 1’s personnel file showed the hiring date was 9/1/23. However, review of the file failed to show Hepatitis B vaccine was documented as per P&P. Further review of the LVN 1’s file failed to show documented evidenced of the pre-employment physical was performed prior to the hiring date. * Review of LVN 3’s personnel file showed the hiring date was 7/30/24. However, review of the file failed to show Hepatitis B vaccine was documented as per P&P. * Review of CHHA 1’s personnel file showed the hiring date was 1/6/24. However, review of the file failed to show Hepatitis B vaccine was documented as per P&P. On 1/29/25 at 1035 hours, an interview and concurrent document review was conducted with the Administrative Assistant/LVN. The Administrative Assistant/LVN was informed and acknowledged the findings. * Review of LVN 1’s personnel file showed the hiring date was 9/1/23. However, review of the file failed to show Hepatitis B vaccine was documented as per P&P. Further review of the LVN 1’s file failed to show documented evidenced of the pre-employment physical was performed prior to the hiring date. * Review of LVN 3’s personnel file showed the hiring date was 7/30/24. However, review of the file failed to show Hepatitis B vaccine was documented as per P&P. * Review of CHHA 1’s personnel file showed the hiring date was 1/6/24. However, review of the file failed to show Hepatitis B vaccine was documented as per P&P. On 1/29/25 at 1035 hours, an interview and concurrent document review was conducted with the Administrative Assistant/LVN. The Administrative Assistant/LVN was informed and acknowledged the findings. b. The agency’s P&P titled Employee Evaluation undated, showed agency staff members are given appraisals of employment after 90 days after the date of hire and annually based on date of hire. Appraisals of skills are given every three years and as necessary. * Review of the CHHA 3’s personnel file showed the hiring date was 9/22/17. The employee’s performance evaluation was conducted annually. However, there was no documented evidenced of the performance evaluation was conducted for the year 2023. In addition, the latest skills competency were conducted on 9/20/20. However, there was no documented evidenced of the skills competency was conducted for the year 2023 as per P&P. On 1/29/25 at 0905 hours, an interview and concurrent document review was conducted with the LVN Case Manager. The LVN Case Manager reviewed the personnel files and acknowledged the findings. * Review of LVN 3’s personnel file showed the hiring date was 7/30/24. Review of the Skills Checklist and Performance Evaluation dated 7/30/24 showed the sections for Self-assess, Preceptor assess and Date. The section on Self assess included the following: -The medication administration techniques: oral, rectal, IM, Sub-q, inhaler/nebulizer, sublingual and Gtts -ear and eye, -Emergency care: call 911 and CPR, -1-800 Hotline # 1-800-228-5234: number and hours of operation, complaints, information on Advance Directives and information on Home Health Care and -Medications: route, frequency, dosage & indication, drug, food interaction, home monitoring program, side effects and adverse reactions. However, on the section for the Preceptor assess and date was left blank. In addition, the section for the employee was dated 1/5/24. However, the employee signature was left blank. Moreover, the evaluator signature and date was left blank. On 1/29/25 at 1035 hours, an interview and concurrent document review was conducted with the Administrative Assistant/LVN. The Administrative Assistant/LVN was informed and acknowledged the findings. c. The agency’s P&P titled Clinical Documentation revised 7/8/09 showed all wounds will be assessed with each visit and must include the following: size measured weekly and PRN, site, location, drainage, cleansing/irrigation and or rinsing medium, medication applied, type of packing, type of dressing, progress or non progress in healing, other notation as appropriate and complete weekly skin wound assessment form and treatment record. Review of Patient 3’s clinical record was initiated on 1/23/25. The clinical record showed the SOC was 6/28/24. The patient was certified for home health services during the certification periods from 10/26/24 to 12/24/24 and 12/25/24 to 2/22/25. The POC, for the certification period from 12/25/24 to 2/22/25, cited SN visits 1W1, 2W8. The POC also showed SN to assess skin breakdown every visit. SN to assess/ evaluate wound (s) at each dressing change and PRN for signs and symptoms of infection. Report to physician any significant changes. SN to perform inspection of patients’ lower extremities every visit and report any alteration in skin integrity to physician. Review of the SN visit notes dated 1/6/25 on the section of narrative showed the SN had performed skin assessment. The patient was assessed to have a wound to the left second toe. However, review of the clinical record failed to show documented evidenced of a complete wound assessment to the patient left second toe was performed as per P&P. In addition, review of the SN notes dated 12/26/24 and 1/3/25, showed the SN had performed wound assessment and treatment to the patients’ right forefoot. However, review of the SN visit notes dated 1/1, 1/6, 1/10, 1/13, 1/17 and 1/20/25 failed to show documented evidenced of the complete wound assessment to the patients right forefoot was performed every visit as per P&P. On 1/29/25 at 0912 hours, an interview and concurrent clinical record review was conducted with the LVN Case Manager. The LVN Case Manager was informed and acknowledged the findings.”

“Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure the agency’s CHHA prepared accurate visit notes for one of eight sampled patients (Patient 1). This failure had the potential for substandard healthcare outcomes for this patient. Findings: Review of Patient 1’s clinical record was initiated on 1/23/25. The clinical record showed the SOC was 6/12/24. The patient was certified for home health services during the certification period from 12/9/24 to 2/6/25. The Aide Care Plan for the certification period dated 12/9/24 to 2/6/25, showed CHHA visits 2W9. The OASIS-E Transfer dated 12/28/24, showed the patient was transferred to an inpatient facility. The CHHA note dated 12/30/24, showed a visit was conducted. Documentation showed the patient’s BP was 123/67 mmHg, pulse was 72 beats per minute, respiration was 17 breath per minute, and temperature was 97.8 degrees Fahrenheit. Documentation showed CHHA 2 performed the following tasks: bed bath completed, assisted to dressing, combed hair, peri and incontinent care performed, hair shampooed, and assisted with transfer. Documentation showed the patient’s skin was clean and dry. Documentation showed CHHA 2 digitally signed the CHHA note. The OASIS-E1 Resumption of Care dated 1/5/25, showed the patient had inpatient hospitalization due to influenza. * Documentation showed CHHA 2 had conducted a visit on 12/30/24, after the patient was transferred to an inpatient facility dated 12/28/24. On 1/29/25 at 0900 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS, Biller, and RN 2. The Administrator/DPCS stated CHHA 2 did not conduct a CHHA visit on 12/30/24. On 1/29/25 at 0900 hours, the Administrator/DPCS, Biller, and RN 2 were informed and acknowledged the finding.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure the completed discharge summaries were sent to the primary care practitioner within five business days of the discharge date for two of two sampled discharged patients (Patients 6 and 7), and the completed transfer summary for one of eight sampled patients (Patient 1). These failures had the potential for not providing the necessary care and services to these patients after discharge from the HHA. Findings: Review of Patient 1’s clinical record was initiated on 1/23/25. The clinical record showed the SOC was 6/12/24. The patient was certified for home health services during the certification period from 12/9/24 to 2/6/25. The OASIS-E Transfer dated 12/28/24, showed the patient was transferred to an inpatient facility. * However, there was no documented evidence the medications that the patient was on at the time of transfer was included in the transfer summary. In addition, there was no documented evidence the transfer summary was sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient within 2 business days of becoming aware of an unplanned transfer. On 1/29/25 at 0900 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS, Biller, and RN 2. They were informed and acknowledged the finding. #. Review of Patient 7’s closed clinical record was initiated on 1/24/25. The closed clinical record showed the SOC was 11/14/24. The patient was certified for home health services during the certification period from 11/14/24 to 1/12/25. The Discharge Summary dated 10/10/25, the reason for discharged was due to being hospitalized. * However, there was no documented evidence the discharge summary was sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA within 5 business days of the patient’s discharge. On 1/29/25 at 0935 hours, an interview and concurrent clinical record review was conducted with the Administrative Assistant/LVN. He was informed and acknowledged the finding. 1. The agency P&P titled Care Coordination Process revised 2/14/14, showed the purpose is to ensure proper handling of the patient throughout the entire process of patient care from initial intake and completion at discharge. The procedures included discharge. The discharge order and a discharge summary are sent to the attending MD. Review of Patient 6’s closed clinical record was initiated on 1/27/25. The clinical record showed the referral date was 2/24/23, and the patient’s OASIS SOC was 3/2/23. The patient was certified for home health services during the certification periods from 8/29/23 to 10/27/23 and 10/28/23 to 12/26/23. The patient was discharged from the HHA on 11/24/23. However, there was no documented evidence the discharge summary was sent to the physician within five business days of the patient’s discharged. In addition, review of the OASIS discharge dated 11/24/23, included a discharge summary. However, the medications list was not included in the discharge summary. On 1/29/25 at 1018 hours, an interview and concurrent clinical record review was conducted with the LVN Case Manager. The LVN Casa Manager was asked if the discharge summary was sent to the physician within 5 business days from discharge. The LVN Case Manager reviewed their files and replied, no documentation as to when the discharge summary was sent to the physician. The LVN Case Manager was also asked if the discharge summary needed to include the list of medications. The LVN Case Manager replied, no per P&P. The LVN Case Manager was informed and acknowledged the findings. The agency P&P titled Care Coordination Process revised 2/14/14, showed the purpose is to ensure proper handling of the patient throughout the entire process of patient care from initial intake and completion at discharge. The procedures include discharge. The discharge order and discharge summary are sent to the attending MD. 1. Review of Patient 6’s closed clinical record was initiated on 1/27/25. The clinical record showed the referral date was 2/24/23, and the patient’s OASIS SOC was 3/2/23. The patient was certified for home health services during the certification periods from 8/29/23 to 10/27/23 and 10/28/23 to 12/26/23. The patient was discharged from the HHA on 11/24/23. However, there was no documented evidence the discharge summary was sent to the physician within five business days of the patient’s discharged. In addition, review of the OASIS discharge dated 11/24/23, included a discharge summary. However, the medications list was not included in the discharge summary. On 1/29/25 at 1018 hours, an interview and concurrent clinical record review was conducted with the LVN Case Manager. The LVN Casa Manager was asked if the discharge summary was sent to the physician within 5 business days from discharge. The LVN Case Manager reviewed their files and replied, no documentation as to when the discharge summary was sent to the physician. The LVN Case Manager was also asked if the discharge summary needed to include the list of medications. The LVN Case Manager replied no. The LVN Case Manager was informed and acknowledged the findings. 2. Review of Patient 1’s clinical record was initiated on 1/23/25. The clinical record showed the SOC was 6/12/24. The patient was certified for home health services during the certification period from 12/9/24 to 2/6/25. The OASIS-E Transfer dated 12/28/24, showed the patient was transferred to an inpatient facility. * However, there was no documented evidence the medications that the patient was on at the time of transfer was included in the transfer summary. In addition, there was no documented evidence the transfer summary was sent to the primary care practitioner or other health care professional who would be responsible for providing care and services to the patient within 2 business days of becoming aware of an unplanned transfer. On 1/29/25 at 0900 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS, Biller, and RN 2. They were informed and acknowledged the finding. 3. Review of Patient 7’s closed clinical record was initiated on 1/24/25. The closed clinical record showed the SOC was 11/14/24. The patient was certified for home health services during the certification period from 11/14/24 to 1/12/25. The Discharge Summary dated 10/10/25, showed the reason for discharge was due to being hospitalized. * However, there was no documented evidence the discharge summary was sent to the primary care practitioner or other health care professional who would be responsible for providing care and services to the patient after discharge from the HHA within 5 business days of the patient’s discharge. On 1/29/25 at 0935 hours, an interview and concurrent clinical record review was conducted with the Administrative Assistant/LVN. He was informed and acknowledged the findings.”